A nurse is assisting with the care of a client who has partial-thickness and full-thickness burns to his upper torso and face. Which of the following actions should the nurse take to prevent infection?

Place new linen on the client's bed every other day.

Change gloves between sites when providing wound care to multiple wounds.

Change the dressing on infected wounds first.

Monitor vital signs every 4 hr.

Answer and Explanation

The Correct Answer is B

A. Place new linen on the client's bed every other day: While changing linen regularly is important for maintaining cleanliness and preventing infection, waiting every other day may not be sufficient for a client with burns, especially if there is wound drainage or soiling. Linens should be changed more frequently, ideally daily or as needed, to ensure cleanliness and prevent the spread of infection.

B. Change gloves between sites when providing wound care to multiple wounds: This is a correct action. Changing gloves between sites when providing wound care helps prevent the spread of infection from one wound to another. It reduces the risk of cross-contamination and helps maintain a sterile environment during wound care procedures.

C. Change the dressing on infected wounds first: This is incorrect. Dressings on infected wounds should be changed promptly to prevent the spread of infection. However, changing the dressing on infected wounds first may lead to contamination of other wound sites if proper precautions are not taken. It's important to follow proper infection control procedures, including changing gloves between wound sites and using aseptic technique.

D. Monitor vital signs every 4 hr: Monitoring vital signs is important for assessing the client's overall condition, but it is not directly related to preventing infection. Vital signs may indicate signs of infection, such as fever or increased heart rate, but they do not prevent infection on their own. Other measures, such as wound care and infection control practices, are more directly related to preventing infection in clients with burns.

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Correct Answer is A

Explanation

A. "My belly doesn't hurt anymore."

- This statement is concerning because sudden relief from severe right lower quadrant pain in a child with a history of nausea, vomiting, and suspected appendicitis may indicate a rupture or perforation of the appendix. When the appendix ruptures, there may be a temporary alleviation of pain due to the release of pressure. However, this situation is critical and requires immediate medical attention to prevent further complications such as peritonitis or sepsis.

B. "I am hungry and thirsty."

- While it's normal for a child to feel hungry and thirsty, especially if they have been experiencing nausea and vomiting, this statement is not necessarily concerning on its own. However, in the context of suspected appendicitis and severe right lower quadrant pain, it's important for the child to remain NPO (nothing by mouth) to prevent complications in case surgery is needed.

C. "I'm tired and want to take a nap."

- Feeling tired and wanting to rest is not uncommon, especially if the child has been experiencing discomfort or pain for a prolonged period. While this statement may indicate fatigue, it's not inherently concerning in the context of suspected appendicitis. However, it's important for the nurse to monitor the child's energy level and overall condition.

D. "I am scared and I want to go home."

- It's understandable for a child to feel scared or anxious, particularly when facing a medical procedure such as surgery. While this statement reflects the child's emotions, it doesn't necessarily indicate a change in their medical condition. However, it's important for the nurse to address the child's fears and provide emotional support while ensuring that the child receives appropriate medical care.

A. Increase in appetite B. Tugging on the affected ear lobe C. Erythema and edema of the affected auricle D. Bluish-green discharge from the ear canal

Correct Answer is B

Explanation

A. Increase in appetite: Otitis media, an infection or inflammation of the middle ear, typically causes discomfort and pain in infants. As a result, they may experience a decrease in appetite rather than an increase.

B. Tugging on the affected ear lobe: Tugging or pulling on the affected ear lobe is a common sign of ear pain in infants with otitis media. It occurs because the pain from the middle ear extends to the outer ear canal.

C. Erythema and edema of the affected auricle: Otitis media primarily affects the middle ear, so erythema (redness) and edema (swelling) are not typically observed on the outer ear (auricle). Instead, these symptoms are more commonly seen in external ear infections, such as otitis externa.

D. Bluish-green discharge from the ear canal: Bluish-green discharge from the ear canal is not a typical finding in otitis media. It may suggest a secondary bacterial infection or another underlying condition, but it is not a characteristic feature of otitis media.

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A nurse is assisting with the care of a client who has partial-thickness and full-thickness burns to his upper torso and face. Which of the following actions should the nurse take to prevent infection?

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